The United Kingdom, Israel, and the USA:

The impact of healthcare systems on health

Sue Anderson, PhD, RN, FNP-BC Co authors:

Cheryl Zlotnick, RN DrPH Vanessa Heaslip, Principal Academic

Declaration

No conflict of interest

Objectives

1. Describe the health care delivery systems and health indicators of the United Kingdom, Israel, and the United States.

2. Develop understanding of how health care delivery in the United Kingdom, Israel, and the United States impacts selected groups.

3. Offer recommendations to reduce health disparity and improve health.

Vulnerable populations

Health disparity increases morbidity and mortality

Lack of/decreased resource access

Increased risk exposure

Often comprised of non-dominant groups

Each country discussed has populations that experience health disparity.

Comparison between Israel, UK and the USA

Health System Access UK

Healthcare is a right

Full access for all

National Health Service – payment not expected

Some degree of health service rationing

Israel Healthcare is a right

Access for all through sick funds

Service depends on basket

USA Healthcare is a commodity

Access may be limited except in emergencies

Payment for services is an issue

The Israel Context

Cheryl Zlotnick RN DrPH Associate Professor

Head, International Study Abroad Program in Nursing Cheryl Spencer Department of Nursing, Faculty of Social Welfare and

Health Sciences University of Haifa 199 Aba Khoushy Ave, Migdal Eskhol, 8th floor, #808 Mount

Carmel, Haifa 3498838, Israel czlotnick@univ.haifa.ac.il

Fundamentals of Israeli Health System

Israel has a national public health system based on tax revenues and government funding.

Regulation and policies on health and medical services, as well as planning, supervision, licensing and coordination is the responsibility of the Ministry of Health.

The National Insurance Health Law of 1994 states that all citizens of Israel are eligible for membership in one of four national health funds (Clalit, Maccabi, Meuhedet, Leumit) that offer a standard "basket of services" to members; the cost and standard benefits are set by law.

The Basket of Services - Israel • Primary Care Services - Visits to clinics, diagnosis, consultations,

treatments from family doctors, specialists and paramedics • Prescriptions (as approved) • Hospitalization and emergency room services • Laboratory services either within the health-fund or if necessary

through an outside facility. The lab costs may be covered partially or fully.

• Certain medical equipment • Certain diagnostic procedures including x-rays and scans • Rehabilitation • Some paramedical services like physiotherapy, speech therapy and

occupational therapy

Vulnerable Populations Israelis are comprised of approximately 75% Jews, 18% Moslem, 3% Christians and others. About a third of Israel’s citizens are immigrants. Almost 10% of Israeli-Jews are ultra-orthodox. Health disparities have been noted among population groups with lower socioeconomic status (e.g., immigrants, Israeli-Arabs and Ultra-orthodox Jews).

Vulnerable Populations

More specifically, • Israeli-Arabs are more likely to smoke and less

likely to use oral health care than the general population. Moreover, they have higher infant mortality rate, lower life expectancy, and higher age-adjusted mortality rates for cardiac disease, diabetes and cancer.

• Immigrants reported feeling discrimination and discrimination was related to lower health status. In particular, Ethiopian immigrants have disproportionately higher rates of diabetes, and lower health care utilization compared to others.

Health System Impact The "Healthy Israel 2020" initiative was established to develop a health promotion and disease prevention blueprint for Israel …to improve the quality of life, extend life expectancy and reduce health disparities. Many health indicators show good health (e.g., infant mortality and life expectancy); however, • health care access is problematic as signs and health-

related information often is available in Hebrew, but needs to be available in Arabic and Russian.

• Israel’s love of technology may impose barriers to access among elderly and immigrant populations.

• supplementary services available with additional cost increases disparities as those with lower income cannot afford these “extras.”

The UK Context Dr Vanessa Heaslip Principal Academic Department of Nursing and Clinical Science Bournemouth University, UK

Health System (UK)

Healthcare predominately provided by NHS (founded 1948). Premise - healthcare is provided on the basis of clinical need rather than ability to pay.

Funded through taxation/national insurance (98.8%) and some charged for services (prescription, dental and optical care) from those who can afford to pay (1.2%).

Rationing and waiting for non urgent services

Due to devolution the UK: 4 separate services (Wales, England, Northern Ireland and Scotland) all funded centrally, but each implemented slightly differently.

Organized into Primary (General practitioner, dentist, opticians, pharmacy) and Secondary care (Hospital and specialist services). In addition, community trusts offering community nursing & mental health services

Vulnerable Populations

Vulnerable Migrants Five times more likely to experience mental

health problems including post-traumatic stress disorder (PTSD), anxiety, depression and phobias.

Gypsy Roma Travellers Die on average 10-15 years younger than the

rest of the general population. Higher rates of both physical and mental ill health, higher smoking rates, poorer birth outcomes and maternal health, and low child immunisation rates

Homeless Much more likely to experience poor mental

health including; drug misuse, alcohol misuse and associated dependencies. As well as depression/other affective disorders, anxiety states, personality disorder, and schizophrenia.

Sex workers Increased risk of sexually transmitted infections

and blood-borne viruses. Higher incident of mental health including drug abuse, also at risk of becoming homeless

On the whole the health of the UK is reasonably good. There is however evidence that some vulnerable groups do less well (Kings Fund 2014, Aspinall 2014). Four such groups are:

Health inequality Lack of standardised reporting • Currently healthcare services do not record

comprehensive national or local level picture of these health needs.

• The ethnic category codes currently used are from the 2001 England and Wales Census (2011 census added Gypsy/Traveller as an ethnic category). Heaslip (2015;2016) argues this has led to this community becoming invisible.

• This lack of comprehensive data set makes it difficult to assess the degree to which these groups access healthcare services, and therefore ways in which healthcare services may inhibit participation.

Vulnerable groups – what we do know • More likely to access secondary care

(Emergency Department) rather than primary care; in the case of the homeless 5 times more likely. Therefore less access to preventative health promotion measures

• Less monitoring of chronic conditions. Therefore accessing healthcare services further along the illness trajectory.

• Healthcare services not always culturally sensitive/responsive to needs. In the case of older Gypsy Roma Travellers literacy is still an issue, yet many healthcare appointments are sent by letter.

The USA Context

Sue Anderson, PhD, RN, FNP-BC Assistant Professor Indiana University South Bend Vera Z. Dwyer College of Health Sciences School of Nursing

Health System (USA)

Large, complex, expensive Payment for services

Insurance (Private, Public, Out-of-Pocket)

Payment system: Creates vulnerability: individuals, families, systematic

Affordable Care Act

Medicaid expansion 19 states opted out of expansion

Marketplace plans Increased number insurance coverage Cost is a barrier

Uninsured

Uninsured Difficulty finding primary care provider Delay preventive health screenings and maintenance Delayed diagnosis for sexually transmitted infections and

HIV Children under-immunized Prescription medicine unaffordable Emergency departments required to screen and

stabilize No mandate for provision of care to uninsured

Uninsured: Who are they?

Working poor families All racial and ethnic groups

Hispanic residents

Non US citizens

Undocumented

Discussion Revisit top causes of death

Preventable causes

Levels of prevention Primary, secondary, tertiary

Healthcare? Access is important Commodity for citizens or a human right? Is it truly healthcare?

The Challenge

Vulnerable populations Lack of culturally appropriate and relevant care

Current system Truly addresses secondary and tertiary levels of prevention

Nursing A long history of public health trailblazing

The Challenge

Looking upstream True primary prevention

Proactive outreach Grassroots effort in communities

Outreach and research with vulnerable populations

The Challenge

Revisit behaviors leading to poor health: Tobacco use, obesity, limited physical activity

Community Continue efforts to educate and encourage smoking cessation

Clean air to breathe

Access to affordable healthy foods

Improved access to safe spaces to be active

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